Questions of trust…?

by Ewen SpeedJun 21, 2013

Photo: Trust from Ellis' Flickr photostream

Another week, another scandal involving the Care Quality Commission (CQC). This time the sorry catalogue of events relates to a maternity unit in Morecambe Bay. As details of the report were leaked prior to publication this week, the tone and tenor of the media coverage was on the CQC cover up in relation to an internal review of the maternity unit in 2010. According to The Guardian, the University Hospitals Morecambe Bay NHS Foundation Trust is currently facing over 30 compensation claims over deaths of, or injuries to, mothers and babies. According to the Daily Mail, 16 babies and 2 mothers are alleged to have died between 2002 and 2011 because of poor care. The Telegraph reports at least 30 ongoing civil negligence claims. This latest tragedy raises fundamental questions about an incompatibility between principles of professional care and principles of professional governance. The perceived necessity to cover up bad practice has taken precedence over the perceived professional ethics of non-maleficence.

Stories such as this raise a number of sociological concerns but these quickly become difficult to articulate when considered against the horrific and highly emotive context of the particular case (just as it was with Mid Staffs). They provoke immediate reactions of anger and disgust, particularly when framed in a context of malpractice and incompetence. These feelings are further compounded when we consider the vulnerability of the patient group. But this reaction must not and cannot be the end of the discussion. Once the need to move beyond these emotional responses is accepted then we move into all-the-more tricky sociological considerations of these events. For example, according to the Office for National Statistics (ONS) last year there were approximately 700,000 births in NHS hospitals in England. For the same period the ONS report neonatal mortality (i.e. deaths in the first 28 days of life) at a level of 2.9 deaths per 1,000 live births in 2011. That is to say, statistically, it would be expcted that 2.9 babies in every 1000 will die in the the first 28 days of life. This rate represents a 57% reduction in neonatal mortality rates from 1981 and shows there are a lot of very competent midwives and well functioning maternity units that are clearly working very well across the country.

This raises an important issue in relation to Morecambe Bay. The fact that these deaths are concentrated in one place, clearly qualifies Morecambe Bay as somewhere requiring close scrutiny. However, and this is crucial, it is an OUTLIER – this case rests on high rates of unexpected deaths, in one place, in a specified time frame. The allegation is that these higher rates of unexpected deaths are due to malpractice or negligence. On the one hand, this charge seems only right and proper, given the excess mortality, but, on the other hand, it does not make any sense to judge the quality of the whole barrel on the basis of the one rotten apple. Unless of course you want to change the wholesaler who you buy your apples from.

Paul Taylor, writing in the London Review of Books, suggests another possible reason. He characterises the UK public enquiry system as working on a principle of ‘identifying the one broken part in the system’. This approach has been very noticeable in the CQC response to Morecambe Bay, amidst claims, to paraphrase the CQC that, “yes we were a bad organisation back then, but we are a much better organisation now”.

This broken part culture creates the context where struggles ensue over who is labeled as the ‘broken part’. Is it the CQC, or is it the University Hospitals Morecambe Bay NHS Foundation Trust? Either way it deflects attention away from government and actually allows them to paint a picture of ineffective regulators coupled to errant professionals, all incapable of doing their jobs. It is of a piece with wider moves away from notions of embodied trust in professionals towards models of enforceable trust. These new models are legitimated through active questioning and distrust of doctors’ values, fuelled by representations of incompetent, self-interested professions, who have pursued their own commercial self-interest and who have been co-opted by private corporate interests. They are clearly a ‘broken part’.

This brings us back to Taylor’s characterisation of UK public enquiries. He compares the UK approach with governance processes in Queensland, Australia. He details how

“Data are obtained from hospitals across the state and actual outcomes compared with expected outcomes in order to generate alerts. The focus is on performance over time rather than on a single number… A broader range of outcomes is considered, not just mortality, and because it was argued that the threshold should be set very low, many hospitals are flagged so that investigations become a normal part of an institution’s commitment to safety. So long as NHS trusts that have a high Hospital Standardised Mortality Ratio continue to be named in the papers and the statistical concept of ‘avoidable death’ is interpreted as providing grounds for criminal prosecution, the argument for a similar system won’t be made here, let alone won, any time soon.”

Discussions of naming and shaming are being played out right now in terms of the CQC. The possibility of criminal prosecution still looms large over the Francis report. These processes speak directly to allegations of CQC’s involvement in cover-ups and purported pay-offs to whistle-blowers. The perceived necessity to cover up bad practice has taken precedent over the perceived professional first principle of non-maleficence. This primary principle of ‘first do no harm’ has been replaced with a principle of ‘first make sure no one sees any harm you may advertently or inadvertently either commit or be aware of’. I am not so naive to presume that cover-ups of incompetence (on the part of the CQC) or malpractice (on the part of specific hospitals) are a new occurrence. But I can’t help but wonder what the connection is between these sorts of cover-ups and models of enforceable trust. These enforceable models require health providers to demonstrate they are doing nothing wrong, whereas an alternative model of trust might require them to demonstrate what they are doing right.

The Queensland model offers a more balanced combination between the two approaches, such that the focus becomes routine monitoring of issues of practice and safety rather than seeking to attribute blame. Enforceable trust, whilst it is sold as ensuring tighter regulation of professionals, simultaneously works to create cultures of secrecy and cover-ups. A model of enforceable trust seems less amenable to principles of non-maleficence and more amenable to principles of management. When management dominates and non-maleficence is backgrounded, we see situations such as Mid Staffs and now Morecambe Bay. Within all of this, the role of government, in determining the shape and tenor of the regulatory framework, is at best backgrounded, if not completely ignored.